This document discusses best practices for delivering bad news to patients and their families in a compassionate manner. It begins by having attendees reflect on their own experiences delivering bad news. The goal is to educate healthcare providers on how to communicate bad news effectively in order to positively influence patient and family reactions. It then discusses various methods and protocols for delivering bad news, including preparing, sharing the information clearly and slowly, and caring for the patient emotionally. Common patient reactions are explored, as well as tips for handling special situations. The document emphasizes allowing patients to process the news at their own pace and maintaining a supportive presence.

1. End-of-Life Care
Conversations
Are you ready?

2. Your Experiences
How many have delivered bad news to someone
in any setting outside of a medical one?
• Was it unexpected?
How many have delivered
bad news to someone in a
setting related to your
clinical position?
• Were you prepared for it?

3. Goal
To educate healthcare providers on how to
communicate bad news compassionately
and effectively in order to positively influence
the reactions and resulting attitudes
of patients and their
family members

4. Objectives
• Define “bad news”
• Discuss importance of delivering bad news well
• Identify three keys in communicating bad news and
effectively demonstrate them
• List “typical” responses to bad news and differentiate
between helpful and unhelpful responses
• Discuss how to handle special situations that may
arise upon receiving bad news
• Explore ways to break bad news by phone

5. Types of Bad News
• A young father learns he has Lou Gehrig’s disease
• A singer is diagnosed with cancer of the larynx
• A teenager has only a couple of months left to live
• A pregnant woman’s ultrasound confirms a
dead fetus
• A breast cancer survivor learns that the cancer
has come back with a vengeance

6. End-of-Life Care Conversations
are Difficult Because…
• Unable to deal with intensity of response
• Fearful of reaction
• Don’t want to take hope
away from patient
• Illness as an indication
of failure
• The task is unpleasant

7. End-of-Life Care Conversations
are Difficult Because… (Cont.)
• Lack of training
• Stress
• Feeling of inadequacy
• Requests by family to withhold information
• Delivering bad news will take time
• Personal fear

8. • Timing
• Life/work disruption
• How the news is broken
• Prior experience
Context Influences
Reaction

9. Definition
“Any news that drastically and negatively
alters the patient’s views of her or his future”
—Robert Buckman
“A threat to a person’s mental or physical well-
being: the upset of an established lifestyle”
—J. T. Ptacek

10. The “Truth” about Bad News
• Bad news cannot be turned into good news
• The gap between the medical reality and the patient’s
expectations defines “how bad” the news is
• The news is considered “bad” from the perspective
of the giver, receiver or both
Everyone is part of this process!

11. Why is This Important?
• Patients have the right to know
• It’s your job
• Informed consent for further care
• Most of them already know or suspect

12. Why It Needs to be Done Well
• It’s a traumatic event
• It sets the stage for Care Plan decisions
• It can result in negative psychological consequences
• Successful delivery can result in:
– Decrease in patient anxiety and depression
– Increase in healthcare worker’s satisfaction
It’s about quality of life for everyone!

13. Remember
Many patients and families remember
more about how bad news was
communicated than anything else
about their care

14. Bad News Communication
Methods
ABCDE Protocol
• Advance preparation
• Build a therapeutic environment/relationship
• Communicate well
• Deal with patient/family reactions
• Encourage and validate emotions

15. Bad News Communication
Methods (Cont.)
SPIKES Protocol
• Setting and listening skills
• Patient perception
• Invitation
• Knowledge
• Explore emotions and empathize
• Strategy and summary

16. Bad News Communication
Methods (Cont.)
Buckman Six-Step Protocol
1. Getting started
2. Finding out how much the patient knows
3. Finding out how much the patient wants to know
4. Sharing the information
5. Responding to the patient’s feelings
6. Planning and follow-through

17. Three Keys to Communicating
Bad News Well
1. Prepare
2. Share
3. Care

18. Prepare
• Plan what will be discussed
• Allow for adequate time
• Location, location, location
• Find out:
– How much the patient
knows
– How much the patient
wants to know

19. Prepare (Cont.)
• Be familiar with all relevant clinical information
• Rehearse what you will say
• Family/friend present
if possible
• Foreshadow the bad news
• Prepare yourself for strong
emotional reactions!

20. Share
• Break the news gently and slowly
• Communicate the information clearly
in small doses
• Wait for a response
• Allow the patient his/her feelings

21. Share (Cont.)
• Acknowledge patient’s emotions
• Ensure retention
• Clarify understanding
• Encourage questions

22. Care
• Respond with caring
and sensitivity
• Provide reassurance
• Actively listen
• Discuss options
• Be available for follow up

23. Common Responses
to Bad News
• Tears
• Anger
• Sadness
• Love
• Anxiety
• Relief
• Denial
• Blame
• Guilt
• Disbelief
• Fear
• Loss
• Shame
• Intellectualization
• “Fight or Flight”
• Leaving the room
• Withdrawal

24. Common Patient Reactions
Helpful
• Denial
• Anger
• Crying
• Fear
• Bargaining
• Realistic hope
• Humor
Unhelpful
• Guilt
• Pathological denial
• Prolonged rage
• Collapse
• Anxiety
• Unrealistic hope
-“Impossible quest”

25. What if…
The patient seems completely unprepared?
• Clarify what the patient understands
• Identify other family members or friends upon
whom the patient relies
Language is a barrier?
• Use an experienced translator when needed
• Brief translator before the interview
• Avoid using family members as primary translators
Your efforts are ineffective?
• Schedule another meeting

26. What if… (Cont.)
Patient/family member gets angry/starts crying?
• Remain calm and supportive
The patient doesn’t understand?
• Be patient. May not be able to comprehend the
information at that moment—try rewording your
statements to clarify
Someone begins to “act out” dangerously?
• Remove yourself from the situation
• Call friend, neighbor and team manager
You are asked about prognosis?
• Talk in terms of quality of life but suggest they get affairs
in order

27. What if… (Cont.)
The patient is a child?
• Parents may not want the child to be told about illness
However:
– Child may perceive there is a problem due to all
the interventions
– As a result, child may feel distrustful and misled
• Ensure psychosocial support for child and family

28. What if… (Cont.)
The family says “don’t tell?”
• You may feel caught between obligation to obtain
informed consent and maintaining a congenial
relationship with family
• Do ask clarifying questions
• Some situations may require significant negotiation

29. Cultural Sensitivity
• Beware of racial, ethnic and cultural pitfalls
• Disclose news non-verbally through inference
• Do not use phrases like:
–“You have cancer”
–“The cancer is incurable”
• Ascertain the patient/family
desires in advance

30. Breaking the News by Phone
• This is not the preferred method
• Ensure you are in a quiet place
• Have sufficient time for the call
• Ensure the patient is in a position to talk
• Confirm the results
• Anticipate emotional reactions/difficult questions
• Provide information clearly and with sensitivity
• Allow time for reaction

31. Breaking the News by
Phone (Cont.)
• Confirm their understanding of discussion
• Offer support and sympathy
• Provide followup procedures/contact information
• If someone answers other than next of kin:
– Determine relationship
– Make effort to determine how to contact next
of kin without creating alarm

32. What specific challenges
do you face?

33. Are you ready?
Make sure you are prepared
enough to break the news!

34. In Summary
By discussing the information sensitively and
allowing the patient/family to take the lead on
decision-making, you give the patient a
measure of control in the process of receiving
and accepting bad news

35. Closing
If end-of-life care conversations are done poorly,
patient and family members may never forgive us.
However, if we do it well, they will never forget us!

36. Questions?